Neonatal Parenteral Nutrition: Basics for the NICU
Sharon Groh-Wargo, PhD, RD, LD Neonatal Nutritionist, MetroHealth Medical Center and Assistant Professor, Departments of Pediatrics and Nutrition, Case Western Reserve University School of Medicine
Objectives: After completing this module the resident will be able to…
Define parenteral nutrition and who needs it Order appropriate NICU parenteral nutrition solutions Evaluate how well a parenteral nutrition regimen meets the needs of specific patients in the NICU
What is Parenteral Nutrition: Terminology
PN: Parenteral Nutrition – intravenous nutritional support TPN: Total Parenteral Nutrition – parenteral nutrition supplying all known essential nutrients intravenously (patient is NPO) PPN: Partial Parenteral Nutrition – parenteral nutrition supplementing oral nutrition Hyperalimentation (“hyperal”) – a vague, commonly used term meaning either partial or total parenteral nutrition
What is Parenteral Nutrition: Content
Macronutrients Carbohydrate: dextrose monohydrate Protein: crystalline amino acids Fat: intravenous fat emulsion (ex Intralipid) Micronutrients Vitamins – 4 fat soluble and 9 water soluble vitamins Macrominerals – calcium. chromium and manganese. potassium. phosphorus and magnesium Electrolytes – sodium. chloride Trace elements – most commonly zinc. copper. less commonly selenium and iron. rarely molybdenum and iodine Miscellaneous constituents Heparin – to protect line integrity – 1 unit/ml Carnitine – to aid in fat metabolism – 10 mg/kg Famotidine – to protect the stomach mucosal surface area
Who Needs TPN or PPN?
Cannot eat Will not eat Should not eat Cannot eat enough
Prematurity is related to many of the above and is the most common reason for PN in the NICU The NICU generally has more patients on PN than the entire rest of the hospital combined
P.Initiation: Goal is by 24 hours of life
The initial PN solution may be just dextrose. electrolytes. Mg) and trace elements Intravenous fat emulsion can be ordered as soon as the amino acid/dextrose solution but no later than 7 days of life
. and/or amino acids. macrominerals (Ca. vitamins. amino acids. and/or electrolytes. and/or calcium gluconate Within the first 48 hours the parenteral nutrition solution should contain dextrose.
5-3 g/kg/d provide balanced and appropriate nutrition for most NICU patients Patients who deserve individualized TPN orders may include those with fluid restrictions. increased fluid requirements or unusual medical/surgical diagoses
Standard solutions found on the TPN order form ordered at usual fluid volumes (100-150 ml/kg/d) and in conjunction with intravenous fat emulsions at a dose between 0.
Glucose/Electrolyte Imbalance Infection Cholestasis: TPN longer than two weeks increases risk direct bilirubin >1.5mg% is diagnostic Osteopenia: Risk factors: prematurity (low mineral stores). TPN (solutions can’t contain sufficient mineral without precipitating) High alkaline phosphotase (>600U/l) and/or low serum phosphorus (<5 mg%)
. diuretics (increased mineral losses).
MetroHealth ‘TPN’ Order Form: Front (left side of slide). Back (right side)
Step by Step TPN ordering
The following slides will show you highlighted sections of the TPN form and take you step by step through the ordering process The first slide of each step will show you the section of the form to be discussed The front of the form is where the actual order is indicated. the back of the form has explanatory information and details about vitamin and mineral content
Step 1: Order Volume and Lipid Dose
5-3 g/kg. infusion time is described on the back of the form
.Step 1 (Continued)
Order daily for exact volume (ml) needed Take to NICU desk to be faxed by 1PM Dosing weight is defined on the back of the form Lipid doses range from 0.
Step 1 (Continued)
Information from the back of the TPN order form is shown on the left side of this slide Top left defines dosing weight Bottom left describes lipid infusion time
Step 2: Choose a Base Solution
AA2.5%) and progress as soon as possible to Solution II (D12%AA2%) Solutions III and IV (D15-20%.5-3%) require a central line Order ‘tailored solution’ when a special glucose or AA% is required Order ‘Neonatal AA’ for NICU patients
.Step 2 (Continued)
Start with Solution I (D10%AminoAcid1.
Step 2 (Continued)
The box on the back of the form at the bottom has general information Choosing ‘Neonatal AA’ on the front of the form fills the TPN order with a pediatric solution containing a mix of essential and nonessential amino acids more appropriate for young infants
Step 3: Order Electrolytes & Minerals
inappropriate adjustments may precipitate
.Step 3 (Continued)
Usual ranges are listed. Na & K commonly adjusted Adjust mEq/kg of Na & K as fluid from TPN changes Adjust chloride % based on acid base balance Choose “NICU guidelines” for Ca & P unless told to change.
Step 3 (Continued)
The table (above) is from the back of the order form Ca and P guidelines are based on (1) day of life. (2) dosing weight.5 mmol/kg P 1 mEq calcium = 217 mg calcium gluconate
. and (3) fluid volume in ml/kg Infants who are over 7 days and on full volume TPN receive 3 mEq/kg Ca & 1.
Step 4: Order Additional Additives
Se and Carnitine as directed Use extra lines for iron dextran (1 mg/kg) with erythropoietin therapy or for other special orders
.Step 4 (Continued)
Vitamins and heparin per guidelines are automatic Trace elements per guidelines unless cholestatic Order Famotidine.
pharmacy may call to ask your permission to delete them – instead ask that the vitamins be halved
. vitamins may increase osmolality.Step 4: Continued
Vitamins (left top) & trace elements (left bottom) from the back of the TPN order form Dose of daily vitamins is based on weight At low solution volume.
Step 5: Signatures. include Pin# and Beeper# (see left side of slide above) Recommended laboratory monitoring is on the back of the form (see right side of slide above) Check direct bilirubin after 2 weeks of TPN
. Final Information
Print and sign your name.
amino acids and intravenous fat): kcal/kg Carbohydrate (glucose load): mg/kg/minute Protein (from amino acid solution): grams/kg Fat (from intravenous fat emulsion): g/kg Electrolytes: Na and K as mEq/kg
.TPN Daily Calculations: Ordering and Assessing Adequacy
Fluid (from all IV lines including medications): ml/kg Energy (from glucose.
Calculate daily fluid allowance by multiplying goal ml/kg X weight (kg) Subtract fluids coming from all dextrose & normal saline IVs. intravenous fat. and enteral feedings Divide remaining fluid by 24 to calculate parenteral nutrition IV rate ml/hour Order Base Solution or tailored solution
Add fluids from all IV and oral sources and divide by the kg weight Initial fluids are ~80 ml/kg Phototherapy increases fluid needs Maintenance fluids are about 150 ml/kg Fluids should be adjusted and individualized often based on laboratory assessment and clinical condition
488 kcal/ml) D15%AA2.Energy (kcal/kg)
D10%AA1.5% (0.5% (0.61 kcal/ml) D20%AA3% (0.4 kcal/ml) D12%AA2% (0.4 kcal/g and protein 4 kcal/g Intravenous fat emulsion 20% (2 kcal/ml) Initial goal (weight neutral): 50-60 kcal/kg Goal (weight gain): 80-100 kcal/kg
.8 kcal/ml) Dextrose 3.
Glucose Load (mg/kg/minute)
Accounts for both infusion rate and %glucose Especially mportant to monitor in the first week of life in infants <1kg at birth Calculation:
ml/kg X % dextrose = g/kg glucose per day g/kg X 1000 mg/g = mg/kg glucose per day mg/kg X 1440 minutes/day = mg/kg/minute
Initial glucose load is 5-8 mg/kg/minute Increase/decrease ~2mg/kg/minute based on serum glucose
02 = 2 g protein) Minimum protein: 1g/kg (replaces daily urinary losses) Protein balance (initial goal): 1-2.5 g/kg Positive protein balance: 2.5 g/kg (for growth)
Fluid volume (ml) X % amino acid = g protein (ex: 100 ml X .
5-1 g/kg Multiply g/kg X 2.Fat (g/kg)
Start with dose of 0.5-1 g/kg meets essential fatty acids needs >1g/kg provides energy
.5 to derive volume Use volume to calculate calories (2 kcal/ml) Increase by 0.5-1 g/kg per day using the smaller dose increase for the smaller babies Reduce or stop lipids if sepsis occurs 0.
adjust according Adjust Na and K as volume from TPN decreases and oral feedings increase (for example. an infant receiving 5 mEq/kg Na per day when on 150 ml/kg TPN does not usually need 5 mEq/kg Na coming from the parenteral nutrition solution when it provides only 50 ml/kg
Start with suggested pediatric ranges unless instructed otherwise Monitor laboratory values closely especially in young and very small babies.
energy (kcal/kg). protein (g/kg). glucose load (mg/kg/minute) should be calculated in young. ELBW infants
. fat (g/kg) and electrolytes (mEq/kg).Summary
Prematurity is a common reason for PN PN is ordered daily in the NICU PN ordered using standard solutions at usual volumes and with NICU guidelines can provide adequate amounts of all KNOWN essential nutrients Daily calculations for each patient should include volume (ml/kg).
for the Parenteral Nutrition Guidelines Working Group. Guidelines on Paediatric Parenteral Nutrition.References
Shulman RJ and Phillips S. Journal of Pediatric Gastroenterology and Nutrition 36: 587-607. 2005. Goulet O. Krohn K. 2003. Shamir R. Journal of Pediatric Gastroenterology and Nutrition
. Koletzko B. Invited Review: Parenteral Nutrition in Infants and Children. Hunt J.
(1) Describe the parenteral solutions you would prescribe for a two day old 680g infant including the hourly rate of the infusion.
1 ml per day calculate:
ml/kg. g protein/kg. kcal/kg.Questions
(2) For an 820g infant on Dextrose 12% Amino Acid 2% at 5 ml/hr and intravenous fat emulsion at 4. and g fat/kg What is your assessment of the above
What is your assessment and how would you treat?
(3) A 4 day old 510g infant is receiving 200ml/kg ‘D12 hyperal’ and now has a blood sugar >200mg%.
1550g on the following PPN regimen:
D12%AminoAcid2% at 1. vitamins and trace elements Lipids at 1 g/kg over 18 hours Similac Special Care 24 with iron 23 ml q 3 hrs What is your assessment?
. Na 6mEq/kg. P. K 3 mEq/kg.5 mEq/kg and NICU guidelines for Ca. Mg 0.9 ml/hr.Questions (continued)
(4) On the first day of service you pick up a former VLBW infant now 4 weeks.